ch-40-me

Question 1

A normal cough reflex includes which of the following phases?

1. irritation
2. inspiration
3. compression
4. expulsion
   a. 1, 2, 3
   b. 1 and 4
   c. 1, 2, 3, and 4
   d. 2 and 3

Answer 1

ANS: C
As shown in Figure 40-1, there are four distinct phases to a normal cough: irritation, inspiration, compression, and expulsion.

Question 2

Which of the following is/are necessary for normal airway clearance?

1. patent airway
2. functional mucociliary escalator
3. effective cough
   a. 1 and 2
   b. 1, 2, 3
   c. 2 and 3
   d. 2

Answer 2

ANS: B

Normal airway clearance requires a patent airway, a functional mucociliary escalator, and an effective cough

Question 3

Which of the following can provoke a cough?

1. anesthesia
2. foreign bodies
3. infection
4. irritating gases
   a. 2 and 4
   b. 1, 2, and 3
   c. 3 and 4
   d. 2, 3, and 4

Answer 3

ANS: D
Infection is a good example of cough stimulation due to an inflammatory process. Foreign bodies can provoke a cough through mechanical stimulation. Chemical stimulation can occur when irritating gases are inhaled (e.g., cigarette smoke). Finally, cold air may cause thermal stimulation of sensory nerves and produce a cough.

Question 4

Which of the following occurs during the compression phase of cough?

1. expiratory muscle contraction
2. opening of the glottis
3. rapid drop in alveolar pressure
   a. 1 and 2
   b. 2 and 3
   c. 1 and 3
   d. 1

Answer 4

ANS: D
During the third or compression phase, reflex nerve impulses cause glottic closure and a forceful contraction of the expiratory muscles

Question 5

Retention of secretions can result in full or partial airway obstruction. Mucus plugging can result in which of the following?

1. hypoxemia
2. atelectasis
3. Shunting
   a. 1, 2, and 3
   b. 1 and 2
   c. 1 and 3
   d. 2 and 3

Answer 5

ANS: A

Full obstruction, or mucus plugging, can result in atelectasis and impaired oxygenation due to shunting

Question 6

Partial airway obstruction can result in all of the following except:

a. increased work of breathing
b. air-trapping or overdistention
c. increased expiratory flows
d. ventilation/perfusion ratio () imbalances

Answer 6

ANS: C
By restricting airflow, partial obstruction can increase the work of breathing and lead to air trapping, overdistention, and ventilation/perfusion () imbalances.

Question 7

A patient with abdominal muscle weakness is having difficulty developing an effective cough. Which of the following phases of the cough reflex are primarily affected in this patient?

1. irritation
2. inspiration
3. compression
4. expulsion
   a. 1, 2, and 3
   b. 2 and 4
   c. 2, 3, and 4
   d. 3 and 4

Answer 7

ANS: D

Question 8

A patient recovering from anesthesia after abdominal surgery is having difficulty developing an effective cough. Which of the following phases of the cough reflex are primarily affected in this patient?

a. irritation
b. inspiration
c. compression
d. expulsion

Answer 8

ANS: A

Question 9

A patient with a tracheostomy tube is having difficulty developing an effective cough. Which of the following phases of the cough reflex are primarily affected in this patient?

a. irritation
b. inspiration
c. compression
d. expulsion

Answer 9

ANS: C

Question 10

A patient with a neuromuscular disorder causing generalized muscle weakness is having difficulty developing an effective cough. Which of the following cough phases are primarily affected in this patient?

a. irritation
b. inspiration
c. compression
d. expulsion

Answer 10

ANS: B

Question 11

All of the following can impair mucociliary clearance in intubated patients except:

a. use of respiratory stimulants
b. tracheobronchial suctioning
c. inadequate humidification
d. high inspired oxygen concentrations

Answer 11

ANS: A
Although suctioning is used to aid secretion clearance, it too can cause damage to the airway mucosa and thus impair mucociliary transport. Inadequate humidification can cause inspissation of secretions, mucus plugging, and airway obstruction. High fractional inspired oxygen concentrations (FIO2) can impair mucociliary clearance, either directly or by causing an acute tracheobronchitis.

Question 12

All of the following drug categories can impair mucociliary clearance in intubated patients except:

a. general anesthetics
b. bronchodilators
c. opiates
d. narcotics

Answer 12

ANS: B

Several common drugs, including some general anesthetics and narcotic-analgesics, can depress mucociliary transport

Question 13

Conditions that can affect airway patency and cause abnormal clearance of secretions include which of the following?

1. foreign bodies
2. tumors
3. inflammation
4. bronchospasm
   a. 1, 2, and 3
   b. 2 and 4
   c. 2, 3, and 4
   d. 1, 2, 3, and 4

Answer 13

ANS: D
Examples include foreign bodies, tumors, and congenital or acquired thoracic anomalies such as kyphoscoliosis. Internal obstruction also can occur with mucus hypersecretion, inflammatory changes, or bronchospasm, further narrowing the lumen

Question 14

Which of the following conditions alter normal mucociliary clearance?

1. bronchospasm
2. cystic fibrosis (CF)
3. ciliary dyskinesia
   a. 1, 2, and 3
   b. 1 and 2
   c. 1 and 3
   d. 2 and 3

Answer 14

ANS: D
Diseases that alter normal mucociliary clearance can also cause secretion retention. CF is a common disorder in this category. In CF, the solute concentration of the mucus is altered because of abnormal sodium and chloride transport. This increases mucus viscosity and impairs its movement up the respiratory tract. Although less common, there are several conditions in which the respiratory tract cilia do not function properly. These ciliary dyskinetic syndromes also can contribute to ineffective airway clearance

Question 15

Conditions that can lead to bronchiectasis include all of the following except:

a. chronic airway infection
b. muscular dystrophy
c. foreign body aspiration
d. obliterative bronchiolitis

Answer 15

ANS: B
Chronic airway inflammation and infection can lead to bronchiectasis, a common finding in both cystic fibrosis and ciliary dyskinetic syndromes. In bronchiectasis, the airway is permanently damaged, dilated, and prone to constant obstruction by retained secretions. Other conditions that can lead to bronchiectasis include chronic obstructive lung diseases, foreign body aspiration, and obliterative bronchiolitis

Question 16

All of the following conditions impair secretion clearance by affecting the cough reflex except:

a. muscular dystrophy
b. amyotrophic lateral sclerosis
c. chronic bronchitis
d. cerebral palsy

Answer 16

ANS: C.
The most common conditions affecting the cough reflex are musculoskeletal and neurological disorders, including muscular dystrophy, amyotrophic lateral sclerosis, spinal muscular atrophy, myasthenia gravis, poliomyelitis, and cerebral palsy.

Question 17

All of the following are goals of airway clearance therapy except:

a. Reverse the underlying disease process.
b. Help mobilize retained secretion.
c. Improve pulmonary gas exchange.
d. Reduce the work of breathing

Answer 17

ANS: A
The primary goal of airway clearance therapy is to help mobilize and remove retained secretions, with the ultimate aim to improve gas exchange and reduce the work of breathing

Question 18

Which of the following acutely ill patients is LEAST likely to benefit from application of chest physical therapy?

a. patient with acute lobar atelectasis
b. patient with copious amounts of secretions
c. patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD)
d. patient with low V/Q due to unilateral infiltrate

Answer 18

ANS: C
Among the acute conditions for which airway clearance therapy may be indicated are (1) acutely ill patients with copious secretions, (2) patients in acute respiratory failure with clinical signs of retained secretions (audible abnormal breath sounds, deteriorating arterial blood gases, chest radiographic changes), (3) patients with acute lobar atelectasis, and (4) patients with V/Q abnormalities due to lung infiltrates or consolidation.

Question 19

Which of the following conditions are associated with chronic production of large volumes of sputum?

1. bronchiectasis
2. pulmonary fibrosis
3. cystic fibrosis
4. chronic bronchitis
   a. 1, 3, and 4
   b. 2 and 4
   c. 1, 2, 3, and 4
   d. 3 and 4

Answer 19

ANS: A
Airway clearance therapy has proved effective in aiding secretion clearance and improving pulmonary function in chronic conditions associated with copious sputum production, including cystic fibrosis and bronchiectasis, and in certain patients with chronic bronchitis

Question 20

In general, chest physical therapy can be expected to improve airway clearance when a patient’s sputum production exceeds what volume?

a. 30 ml/day
b. 20 ml/day
c. 15 ml/day
d. 10 ml/day

Answer 20

ANS: A
In general, sputum production must exceed 25 to 30 ml/day for airway clearance therapy to significantly improve secretion removal.

Question 21

Which of the following measures would you use to ask patients for the presence of copious mucus production?

a. 1 pint
b. 1 ounce
c. 1 gallon
d. 1 tablespoon

Answer 21

ANS: B

1 ounce is used

Question 22

What are the best documented preventive uses of airway clearance therapy?

1. Prevent retained secretions in the acutely ill.
2. Maintain lung function in cystic fibrosis.
3. Prevent postoperative pulmonary complications
   a. 1, 2, and 3
   b. 1 and 2
   c. 1 and 3
   d. 2 and 3

Answer 22

ANS: B
The best-documented preventive uses of airway clearance therapy include (1) body positioning and patient mobilization to prevent retained secretions in the acutely ill and (2) postural drainage, percussion, and vibration (PDPV) combined with exercise to maintain lung function in cystic fibrosis

Question 23

When assessing the potential need for postoperative airway clearance for a patient, all of the following factors are relevant except:

a. patient’s age and respiratory history
b. nature and duration of current surgery
c. number of prior surgical procedures
d. type of anesthesia (e.g., local versus general)

Answer 23

ANS: C

Question 24

All of the following laboratory data are essential in assessing a patient’s need for airway clearance therapy except:

a. chest radiograph
b. pulmonary function tests (PFTs)
c. hematology results
d. ABGs/oxygen saturation

Answer 24

ANS: C

Question 25

Key considerations in initial and ongoing patient assessment for chest physical therapy include which of the following?

1. posture and muscle tone
2. breathing pattern and ability to cough
3. sputum production
4. cardiovascular stability
   a. 1, 2, and 3
   b. 2 and 4
   c. 1, 2, 3, and 4
   d. 3 and 4

Answer 25

ANS: C

Question 26

Which of the following clinical signs indicate that a patient is having a problem with retained secretions?

1. lack of sputum production
2. labored breathing
3. development of a fever
4. increased inspiratory and expiratory crackles
   a. 2 and 4
   b. 1, 2, and 3
   c. 3 and 4
   d. 1, 2, 3, and 4

Answer 26

ANS: D
Bedside findings such as a loose, ineffective cough, labored breathing pattern, decreased/bronchial breath sounds, coarse inspiratory and expiratory crackles, tachypnea, tachycardia, or fever may indicate a potential problem with retained secretions

Question 27

All of the following are considered airway clearance therapies except:

a. postural drainage and percussion
b. incentive spirometry
c. positive airway pressure
d. percussion, vibration, and oscillation

Answer 27

ANS: B
There are five general approaches to airway clearance therapy, which can be used alone or in combination. These approaches include (1) postural drainage therapy (including turning, percussion, and vibration), (2) coughing and related expulsion techniques, (3) positive airway pressure (PAP) adjuncts (positive expiratory pressure [PEP], continuous PAP [CPAP], expiratory PAP [EPAP]), (4) high-frequency compression/oscillation methods, and (5) mobilization and exercise.

Question 28

The application of gravity to achieve specific clinical objectives in respiratory care best describes which of the following?

a. breathing exercises
b. postural drainage therapy
c. hyperinflation therapy
d. directed coughing

Answer 28

ANS: B

Question 29

Postural drainage should be considered in all of the following situations except:

a. in patients with chronic obstructive lung disease
b. in patients who expectorate more than 25 to 30 ml sputum per day
c. in the presence of atelectasis caused by mucus plugging
d. in patients with cystic fibrosis or bronchiectasis

Answer 29

ANS: A

Question 30

Absolute contraindications for postural drainage include which of the following?

1. head and neck injury (until stabilized)
2. active hemorrhage with hemodynamic instability
3. uncontrolled airway at risk for aspiration

Answer 30

ANS: A

Question 31

Which of the following is NOT a hazard or complication of postural drainage therapy?

a. cardiac arrhythmias
b. increased intracranial pressure
c. acute hypotension
d. pulmonary barotraumas

Answer 31

ANS: D

Question 32

Primary objectives for turning include all of the following except to:

a. prevent postural hypotension
b. promote lung expansion
c. prevent retention of secretions
d. improve oxygenation

Answer 32

ANS: A

The primary purposes of turning are to promote lung expansion, improve oxygenation, and prevent retention of secretions

Question 33

Which if the following is the only absolute contraindication to turning?

a. when the patient cannot or will not change body position
b. when poor oxygenation is associated with unilateral lung disease
c. when the patient has or is at high risk for atelectasis
d. when the patient has unstable spinal cord injuries

Answer 33

ANS: D

There are only two absolute contraindications to turning: unstable spinal cord injuries and traction of arm abductors.

Question 34

Which of the following is/are TRUE of postural drainage?

1. It is most effective in disorders causing excessive sputum.
2. It is most effective in head-down positions greater than 25 degrees.
3. It requires adequate systemic hydration to be effective.
4. It improves mucociliary clearance in normal subjects.
5. It improves pulmonary function in stable chronic obstructive pulmonary disease patients
   a. 2 and 4
   b. 1, 2, and 3
   c. 3 and 5
   d. 1, 2, and 4

Answer 34

ANS: B
Postural drainage is most effective in conditions characterized by excessive sputum production (greater than 25 to 30 ml/ day). For maximum effect, head-down positions should exceed 25 degrees below horizontal. Postural drainage is not likely to succeed unless and until adequate systemic and airway hydration is ensured

Question 35

In which of the following patients would you consider modifying any head-down positions used for postural drainage?

1. a patient with unstable blood pressure
2. a patient with a cerebrovascular disorder
3. a patient with systemic hypertension
4. a patient with orthopnea
   a. 1, 2, 3, and 4
   b. 2 and 4
   c. 2, 3, and 4
   d. 2 and 4

Answer 35

ANS: A
You may need to modify head-down positions in patients with unstable cardiovascular status, hypertension, cerebrovascular disorders, or dyspnea related to changes in position

Question 36

In setting up a postural drainage treatment schedule for a postoperative patient, which of the following information would you try to obtain from the patient’s nurse?

1. patient’s medication schedule
2. patient’s meal schedule
3. location of surgical incision
   a. 1 and 2
   b. 2 and 3
   c. 1 and 3
   d. 1, 2, and 3

Answer 36

ANS: D
To avoid gastroesophageal reflux and the possibility of aspiration, you should schedule treatment times before or at least 1.5 to 2 hours after meals or tube feedings. If the patient assessment indicates that pain may hinder treatment implementation, you also should consider coordinating the treatment regimen with prescribed pain medication

Question 37

A patient about to receive postural drainage and percussion is attached to an electrocardiographic (ECG) monitor and is receiving both intravenous (IV) solutions and O2 (through a nasal cannula). Which of the following actions would be appropriate for this patient?

a. Cancel the therapy because the patient cannot be repositioned.
b. Inspect and adjust the equipment to ensure function during therapy.
c. Turn off the ECG monitor, but keep the IV line and O2 going.
d. Turn off the IV line, but keep the monitor on and the O2 going.

Answer 37

ANS: B
Inspect any monitoring leads, IV tubing, and O2 therapy equipment connected to the patient; if necessary, make adjustments to ensure continued function during the procedure.

Question 38

Which of the following are mandatory components of the preassessment for postural drainage?

1. vital signs
2. bedside pulmonary function tests
3. auscultation
   a. 1 and 2
   b. 2 and 4
   c. 1 and 3
   d. 1, 2, and 3

Answer 38

ANS: C

Before starting the procedure, measure the patient’s vital signs and auscultate the chest.

Question 39

If a patient’s chest radiograph shows infiltrates in the posterior basal segments of the lower lobes, what postural drainage position would you recommend?
a. head down, patient supine with a pillow under knees
b. patient prone with a pillow under head, bed flat
c patient supine with a pillow under knees, bed flat
d. head down, patient prone with a pillow under abdomen

Answer 39

ANS: D

Question 40

A physician orders postural drainage for a patient with an abscess in the right middle lobe. Which of the following positions would you recommend for this patient?

a. head down, patient prone with a pillow under abdomen
b. head down, patient supine with a pillow under knees
c. patient supine with a pillow under knees, bed flat
d. head down, patient half-rotated to left, right lung up

Answer 40

ANS: D

Question 41

A physician orders postural drainage for a patient with aspiration pneumonia in the superior segments of the left lower lobe. Which of the following positions would you recommend for this patient?

a. patient prone with a pillow under abdomen, bed flat
b. head down, patient prone with a pillow under abdomen
c. head down, patient supine with a pillow under knees
d. patient supine with a pillow under knees, bed flat

Answer 41

ANS: A`

Question 42

A physician orders postural drainage for a patient with aspiration pneumonia in the anterior segments of the upper lobes. Which of the following positions would you recommend for this patient?

a. head down, patient prone with a pillow under abdomen
b. patient supine with a pillow under knees, bed flat
c. head down, patient supine with a pillow under knees
d. patient prone with a pillow under abdomen, bed flat

Answer 42

ANS: B

Question 43

If tolerated, a specified postural drainage position should be maintained for at least how long?

a. 1 to 2 minutes
b. 3 to 5 minutes
c. 20 to 30 minutes
d. 3 to 15 minutes

Answer 43

ANS: D
Maintain the indicated position for a minimum of 3 to 15 minutes if tolerated, and longer if good sputum production results

Question 44

While reviewing the chart of a patient receiving postural drainage therapy, you notice that the patient tends to undergo mild desaturation during therapy (a drop in SpO2 from 93% to 89% to 90%). Which of the following would you recommend to manage this problem?

a. Increase the patient’s FIO2 during therapy.
b. Discontinue the postural drainage therapy entirely.
c. Discontinue the percussion and vibration only.
d. Decrease the frequency of treatments.

Answer 44

ANS: A

Question 45

Why is strenuous patient coughing during postural drainage in a head-down position contraindicated?

a. It can impair the mucociliary clearance mechanism.
b. It can increase expiratory airway resistance (Raw).
c. It can cause air trapping and pulmonary distension.
d. It can markedly increase intracranial pressure (ICP).

Answer 45

ANS: D

When using the head-down position, the patient should avoid strenuous coughing, because this will markedly raise ICP.

Question 46

Soon after you initiate postural drainage in a Trendelenburg position, the patient develops a vigorous and productive cough. Which of the following actions would be appropriate at this time?

a. Maintain the drainage position while carefully watching the patient.
b. Move the patient to the sitting position until the cough subsides.
c. Stop the treatment at once and report the incident to the nurse.
d. Drop the head of the bed farther and encourage more coughing.

Answer 46

ANS: B

If the procedure causes vigorous coughing, have the patient sit up until the cough subsides

Question 47

All of the following would indicate a successful outcome for postural drainage therapy except:

a. decreased sputum production
b. normalization in ABGs
c. improved breath sounds
d. improvement in chest radiograph

Answer 47

ANS: A

Question 48

All of the following responses indicate that postural drainage should be terminated except:

a. severe tachycardia
b. complaint of discomfort
c. irregular blood pressure
d. severe bradycardia

Answer 48

ANS: B

Question 49

Which of the following should be charted after completing a postural drainage treatment?

1. amount and consistency of sputum produced
2. patient tolerance of procedure
3. position(s) used (including time)
4. any untoward effects observed
   a. 1, 2, and 3
   b. 2 and 4
   c. 1, 2, 3, and 4
   d. 3 and 4

Answer 49

ANS: C
In your chart entry include the position(s) used, time in position, patient tolerance, subjective and objective indicators of treatment effectiveness (including the amount, color, and consistency of sputum produced) and any untoward effects observed

Question 50

Percussion should NOT be performed over which of the following areas?

1. surgery sites
2. bony prominences
3. fractured ribs
   a. 3
   b. 1 and 2
   c. 2 and 3
   d. 1, 2, and 3

Answer 50

ANS: D
Take care to avoid tender areas or sites of trauma or surgery, and never percuss directly over bony prominences, such as the clavicles or vertebrae.

Question 51

Properly performed chest vibration is applied at what point?

a. throughout inspiration
b. at the end of expiration
c. at the start of inspiration
d. throughout expiration

Answer 51

ANS: D

Vibration sometimes is used together with percussion but is limited to application during exhalation

Question 52

Directed coughing is useful in helping to maintain airway clearance in all of the following cases except:

a. bronchiectasis
b. acute asthma
c. cystic fibrosis
d. spinal cord injury

Answer 52

ANS: B

Question 53

Indications for directed coughing include all of the following except to:

a. enhance other airway clearance therapies
b. help patients with tuberculosis clear secretions
c. help prevent postoperative pulmonary complications
d. obtain sputum specimens for diagnostic analysis

Answer 53

ANS: B

Question 54

All of the following are contraindications for directed coughing except the presence of:

a. infection spread by droplet nuclei
b. elevated intracranial pressure or intracranial aneurysm
c. reduced coronary artery perfusion
d. necrotizing pulmonary infection

Answer 54

ANS: D

Question 55

For which of the following patients directed coughing might be contraindicated?

1. patient with poor coronary artery perfusion
2. postoperative upper-abdominal surgery patient
3. long-term care patient with retained secretions
4. patient with an acute unstable spinal injury
   a. 2 and 3
   b. 1, 2, and 3
   c. 1 and 4
   d. 2, 3, and 4

Answer 55

ANS: C

Question 56

What factors can hinder effective coughing?

1. artificial airways
2. neuromuscular disease
3. systemic dehydration
4. pain or fear of pain
5. use of expectorants
   a. 1, 2, and 4
   b. 2, 4, and 5
   c. 1, 2, 3, and 4
   d. 1, 2, 3, 4, and 5

Answer 56

ANS: C
Some patients with advanced chronic obstructive pulmonary disease or severe restrictive disorders (including neurologic, muscular, or skeletal abnormalities) may not be able to generate an effective spontaneous cough. Likewise, pain or fear of pain caused by coughing may limit the success of directed cough. Systemic dehydration, thick, tenacious secretions, artificial airways, or the use of central nervous system depressants can thwart efforts to implement an effective directed cough regimen.

Question 57

Key consideration in teaching a patient to develop an effective cough regimen includes which of the following?

1. strengthening of the expiratory muscles
2. instruction in breathing control
3. instruction in proper positioning
   a. 2 and 3
   b. 1 and 2
   c. 1, 2, and 3
   d. 1 and 3

Answer 57

ANS: C
The three most important aspects involved in patient teaching are (1) instruction in proper positioning, (2) instruction in breathing control, and (3) exercises to strengthen the expiratory muscles.

Question 58

What is the ideal patient position for directed coughing?

a. sitting with one shoulder rotated inward, the head and spine slightly flexed
b. supine, with knees slightly flexed and feet braced
c. prone, with the head and spine slightly flexed
d. supine, with forearms relaxed and feet support

Answer 58

ANS: A

The patient should assume a sitting position with one shoulder rotated inward and the head and spine slightly flexed

Question 59

A patient recovering from abdominal surgery is having difficulty developing an effective cough. Which of the following actions would you recommend to aid this patient in generating a more effective cough?

1. coordinating coughing with pain medication
2. using the forced expiration technique (FET)
3. supplying manual epigastric compression
4. “splinting” the operative site
   a. 1, 2, and 4
   b. 1, 2, and 3
   c. 3 and 4
   d. 2, 3, and 4

Answer 59

ANS: A
The postoperative regimen can be enhanced by coordinating the coughing sessions with prescribed pain medication and assisting the patient in splinting the operative site. This may initially be accomplished by the clinician, using his/her hands to support the area of incision. Eventually, the patient can learn to use a pillow to splint the incision site. The FET may also be of value in these patients

Question 60

Strenuous expiratory efforts in some chronic obstructive pulmonary disease (COPD) patients limit the effectiveness of coughing. Why is this so?

a. The accessory muscles of inspiration oppose the exhalation.
b. All COPD patients have severe abdominal muscle weakness.
c. High expiratory pleural pressures compress the small airways.
d. Strenuous expiration causes the upper airway to collapse.

Answer 60

ANS: C
In some patients with COPD, the high pleural pressures during a forced cough may compress the smaller airways and limit the cough’s effectiveness

Question 61

A chronic obstructive pulmonary disease patient cannot develop an effective cough. Which of the following would you recommend to help this patient generate a more effective cough?

1. enhancing expiratory flow by bending forward at the waist
2. using short, expiratory bursts or the “huffing” method
3. using only moderate (as opposed to full) inspiration
4. having the patient “tense” the neck muscles while coughing
   a. 2 and 4
   b. 1, 2, and 3
   c. 3 and 4
   d. 1, 2, and 4

Answer 61

ANS: B

Question 62

A nurse explains to you that a certain neuromuscular patient cannot develop a good cough. Which of the following would you consider to manage this patient’s clearance problem?

1. combining manual chest compression with suctioning
2. coordinating the coughing regimen with pain medication
3. using the autogenic drainage method
4. using mechanical insufflation-exsufflation
   a. 1 and 4
   b. 1, 2, and 3
   c. 2 and 3
   d. 1, 2, and 4

Answer 62

ANS: A
If this problem results in retained secretions, there are only three options: (1) placement of an artificial airway and removal of secretions by tracheobronchial suctioning (see Chapter 33), (2) manually assisted cough, and (3) mechanical insufflation-exsufflation

Question 63

Which of the following is false about the FET?

a. It causes less bronchiolar collapse than traditional coughing.
b. It occurs from mid to low lung volume without glottis closure.
c. It has a period of diaphragmatic breathing and relaxation.
d. It occurs from mid to high lung volume without glottis closure.

Answer 63

ANS: D
The FET, or huff cough, consists of one or two forced expirations of middle to low lung volume without closure of the glottis, followed by a period of diaphragmatic breathing and relaxation. The goal of this method is to help clear secretions with less change in pleural pressure and less likelihood of bronchiolar collapse.

Question 64

Maintaining an open glottis during coughing (as with the FET) can help to minimize increases in pleural pressure and lessen the likelihood of bronchiolar collapse. Which of the following techniques can aid the practitioner in teaching the patient this maneuver?

a. having the patient inhale slowly through the nose
b. having the patient phonate or “huff” during expiration
c. having the patient “tense” the neck muscles while coughing
d. telling the patient to exert effort, as in straining at stool

Answer 64

ANS: B

To help keep the glottis open during an FET, the patient is taught to phonate or “huff” during expiration.

Question 65

Whether using traditional methods or the FET, a period of diaphragmatic breathing and relaxation should always follow attempts at coughing. What is the purpose of this approach?

a. to restore the patient’s SO2
b. to restore lung volume and minimize fatigue
c. to allow the patient time to ask questions
d. to decrease the likelihood of acute air-trapping

Answer 65

ANS: B

Question 66

What is the correct sequence of actions during the active cycle of breathing (ACB) method?

1. relaxation and breathing control
2. three or four thoracic expansion exercises
3. one or two FETs (huffs)
   a. 1, 2, 1, and 3
   b. 1, 3, 1, and 2
   c. 3, 1, 2, and 1
   d. 1, 3, 2, and 1

Answer 66

ANS: A

See Box

Question 67

During autogenic drainage, when should patients be encouraged to cough?

a. throughout the procedure
b. after phase 1 only
c. after phase 2 only
d. after phase 3 only

Answer 67

ANS: D

Coughing should be suppressed until all three breathing phases are completed

Question 68

What does phase 1 of autogenic drainage involve?
a. breathing at low to mid-lung volumes
b. an inspiratory capacity maneuver, followed by breathing at low lung volumes
c. vigorous coughing using the FET
d. progressive breaths at higher and higher lung volumes
ANS: B

Answer 68

ANS: B

Question 69

What happens during the exsufflation phase of mechanical insufflation-exsufflation?

1. Airway pressure is abruptly decreased to –30 to –50 cm H2O.
2. Negative airway pressure is maintained for 2 to 3 seconds.
3. Peak expiratory “cough” flows reach near normal values.
   a. 1 and 2
   b. 2 and 3
   c. 1 and 3
   d. 1, 2, and 3

Answer 69

ANS: D
The airway pressure is then abruptly reversed to −30 to −50 cm H2O and maintained for 2 to 3 seconds. Peak expiratory “cough” flows obtained with this device are in the normal range (mean of 7.5 L/sec), far better than can be achieved with manually assisted coughing.

Question 70

A typical mechanical insufflation-exsufflation treatment session should continue until what point?

1. Secretions are cleared.
2. The vital capacity (VC) returns to baseline.
3. The SpO2 returns to baseline.
   a. 2 and 3
   b. 1 and 2
   c. 1, 2, and 3
   d. 1 and 3

Answer 70

ANS: C

This process is repeated five or more times until secretions are cleared and the VC and SpO2 return to baseline

Question 71

Under which of the following conditions would mechanical insufflation-exsufflation with an oronasal mask probably NOT be effective

1. if the glottis collapses during exsufflation
2. presence of fixed airway obstruction
3. presence of a chronic neuromuscular disorder
   a. 2 and 3
   b. 1 and 2
   c. 1, 2, and 3
   d. 1 and 3

Answer 71

ANS: B
Mechanical insufflation-exsufflation via an oronasal interface is effective, provided that there is no fixed airway obstruction or glottic collapse during exsufflation.

Question 72

Which of the following are potential indications for positive airway pressure therapies?

1. reduce air-trapping in asthma or chronic obstructive pulmonary disease
2. help mobilize retained secretions
3. prevent or reverse atelectasis
4. optimize bronchodilator delivery
   a. 2 and 4
   b. 1, 2, and 3
   c. 3 and 4
   d. 1, 2, 3, and 4

Answer 72

ANS: D

Question 73

Contraindications for positive airway pressure therapies include all of the following except:

a. intracranial pressure exceeding 20 mm Hg
b. recent facial, oral, or skull surgery or trauma
c. preexisting pulmonary barotrauma (e.g., pn eumothorax)
d. air-trapping/pulmonary overdistention in chronic obstructive pulmonary disease

Answer 73

ANS: D

Question 74

All of the following are hazards of positive airway pressure therapies (EPAP, PEP, CPAP) except:

a. decreased venous return
b. epistaxis
c. pulmonary barotrauma
d. increased intracranial pressure

Answer 74

ANS: B

Question 75

Hazards of positive airway pressure therapies associated with the apparatus used include which of the following?

1. increased work of breathing
2. claustrophobia
3. epistaxis
4. vomiting and aspiration
5. skin breakdown and discomfort
   a. 1, 3, and 4
   b. 2, 3, 4, and 5
   c. 1, 2, 3, 4, and 5
   d. 3, 4, and 5

Answer 75

ANS: C

Question 76

A physician orders positive expiratory pressure therapy for a 14-year-old child with cystic fibrosis. All of the following responses should be monitored on this patient except:

a. peak flow or forced expiratory volume in 1 second (FEV1) per forced vital capacity percentage
b. patient’s minute volume
c. quantity and character of sputum
d. breath sounds

Answer 76

ANS: B

Question 77

Which of the following best describes positive expiratory pressure (PEP) therapy?

a. expiration against a variable flow resistance
b. expiration against a fixed threshold resistance
c. inspiration against a variable flow resistance
d. inspiration against a fixed threshold resistance

Answer 77

ANS: A

PEP therapy involves active expiration against a variable flow resistance.

Question 78

In theory, how does positive expiratory pressure (PEP) help to move secretions into the larger airways?

1. filling underaerated segments through collateral ventilation
2. preventing airway collapse during expiration
3. causing bronchodilation during inspiration
   a. 2 and 3
   b. 1 and 2
   c. 1, 2, and 3
   d. 1 and 3

Answer 78

ANS: B
In theory, PEP helps move secretions into the larger airways by (1) filling underaerated or nonaerated segments via collateral ventilation and (2) preventing airway collapse during expiration

Question 79

Proper instructions for positive expiratory pressure include all of the following except:

a. Take in a breath that is larger than normal, but do not fill lungs completely.
b. Exhale forcefully and maintain an expiratory pressure of 10 to 20 cm H2O.
c. After 10 to 20 breaths, take two or three “huff”’ coughs, and rest as needed.
d. Repeat the cycle 4 to 8 times, not to exceed 20 minutes

Answer 79

ANS: B

Question 80

A physician orders bronchodilator drug therapy in combination with positive expiratory pressure (PEP). Which of the following methods could you use to provide this combined therapy?

1. Attach a dry powder inhaler in-line with the PEP apparatus.
2. Attach a metered-dose inhaler to the system’s one-way valve inlet.
3. Place a small-volume nebulizer in-line with the PEP apparatus.
   a. 2 and 3
   b. 1 and 2
   c. 1, 2, and 3
   d. 1 and 3

Answer 80

ANS: A

Question 81

What is the movement of small volumes of air back and forth in the respiratory tract at high frequencies (12 to 25 Hz) called?

a. tidal breathing
b. active cycle breathing
c. oscillation
d. huffing

Answer 81

ANS: C
As applied to airway clearance, oscillation refers to the rapid vibratory movement of small volumes of air back and forth in the respiratory tract

Question 82

Which of the following parts are required to conduct high-frequency external chest wall compression?

1. variable air-pulse generator
2. expiratory flow resistor with one-way valve
3. nonstretch inflatable thoracic vest
   a. 1 and 2
   b. 2 and 3
   c. 1 and 3
   d. 1, 2, and 3

Answer 82

ANS: C
High-frequency chest wall oscillation is accomplished by using a two-part system: (1) a variable air-pulse generator and (2) a nonstretch inflatable vest that covers the patient’s entire torso (The Vest airway clearance system).

Question 83

All of the following are typical of high-frequency external chest wall compression therapy except:
a. 30-minute therapy sessions
b. oscillations at 5 to 25 Hz
c. 
one to six sessions per day
d.
long inspiratory oscillations

Answer 83

ANS: D
Typically, respiratory therapists perform 30-minute therapy sessions at oscillatory frequencies between 5 and 25 hertz (Hz). Depending on need and response, between one and six therapy sessions may occur per day

Question 84

Which of the following are potential indications for positive airway pressure therapies?

1. reduce air-trapping in asthma or chronic obstructive pulmonary disease
2. help mobilize retained secretions
3. prevent or reverse atelectasis
4. optimize bronchodilator delivery
   a. 2 and 4
   b. 1, 2, and 3
   c. 3 and 4
   d. 1, 2, 3, and 4

Answer 84

ANS: D

Question 85

Contraindications for positive airway pressure therapies include all of the following except:

a. intracranial pressure exceeding 20 mm Hg
b. recent facial, oral, or skull surgery or trauma
c. preexisting pulmonary barotrauma (e.g., pneumothorax)
d. air-trapping/pulmonary overdistention in chronic obstructive pulmonary disease

Answer 85

ANS: D

Question 86

All of the following are hazards of positive airway pressure therapies (EPAP, PEP, CPAP) except:

a. decreased venous return
b. epistaxis
c. pulmonary barotrauma
d. increased intracranial pressure

Answer 86

ANS: B

Question 87

Hazards of positive airway pressure therapies associated with the apparatus used include which of the following?

1. increased work of breathing
2. claustrophobia
3. epistaxis
4. vomiting and aspiration
5. skin breakdown and discomfort
   a. 1, 3, and 4
   b. 2, 3, 4, and 5
   c. 1, 2, 3, 4, and 5
   d. 3, 4, and 5

Answer 87

ANS: C

Question 88

A physician orders positive expiratory pressure therapy for a 14-year-old child with cystic fibrosis. All of the following responses should be monitored on this patient except:

a. peak flow or forced expiratory volume in 1 second (FEV1) per forced vital capacity percentage
b. patient’s minute volume
c. quantity and character of sputum
d. breath sounds

Answer 88

ANS: B

Question 89

Which of the following best describes positive expiratory pressure (PEP) therapy?

a. expiration against a variable flow resistance
b. expiration against a fixed threshold resistance
c. inspiration against a variable flow resistance
d. inspiration against a fixed threshold resistance

Answer 89

ANS: A

Question 90

In theory, how does positive expiratory pressure (PEP) help to move secretions into the larger airways?

1. filling underaerated segments through collateral ventilation
2. preventing airway collapse during expiration
3. causing bronchodilation during inspiration
   a. 2 and 3
   b. 1 and 2
   c. 1, 2, and 3
   d. 1 and 3

Answer 90

ANS: B

Question 91

Proper instructions for positive expiratory pressure include all of the following except:

a. Take in a breath that is larger than normal, but do not fill lungs completely.
b. Exhale forcefully and maintain an expiratory pressure of 10 to 20 cm H2O.
c. After 10 to 20 breaths, take two or three “huff”’ coughs, and rest as needed.
d. Repeat the cycle 4 to 8 times, not to exceed 20 minutes

Answer 91

ANS: B

Question 92

A physician orders bronchodilator drug therapy in combination with positive expiratory pressure (PEP). Which of the following methods could you use to provide this combined therapy?

1. Attach a dry powder inhaler in-line with the PEP apparatus.
2. Attach a metered-dose inhaler to the system’s one-way valve inlet.
3. Place a small-volume nebulizer in-line with the PEP apparatus.
   a. 2 and 3
   b. 1 and 2
   c. 1, 2, and 3
   d. 1 and 3

Answer 92

ANS: A

Question 93

Patients can control a flutter valve’s pressure by changing what?

a. their inspiratory flow
b. the angle of the device
c. their expiratory flow
d. the expired volume

Answer 93

ANS: C

Patients can control the pressure by changing their expiratory flows

Question 94

Advantages of the flutter valve over other airway clearance methods include all of the following except:

a. good patient acceptance
b. greater effectiveness
c. full portability
d. independent use

Answer 94

ANS: B
The flutter valve is readily accepted by patients, inexpensive, and fully portable and does not require caregiver assistanc

Question 95

Which of the following is not an advantage of the Acapella over the flutter?

a. It can customize frequency.
b. It can be used in any posture.
c. It is more portable.
d. It can customize flow resistan

Answer 95

ANS: C
The Acapella can customize, based on clinical needs, both the frequency and flow resistance by adjusting the dial. Also, it can be used in any posture, including sitting, standing, and reclining.

Question 96

Which of the following should be considered when selecting a airway clearance strategy?

1. patient’s goals, motivation, and preferences
2. effectiveness and limitations of technique or method
3. patient’s age, ability to learn, and tendency to fatigue
4. need for assistants, equipment, and cost
   a. 1, 2, and 3
   b. 1, 3, and 4
   c. 2 and 3
   d. 1, 2, 3, and 4

Answer 96

ANS: D

Question 97

Which of the following airway clearance techniques would you recommend for a 15-month-old infant with cystic fibrosis?

a. postural drainage, percussion, and vibration
b. positive expiratory pressure therapy
c. mechanical insufflation-exsufflation
d. intrapulmonary percussive ventilation

Answer 97

ANS: A

Question 98

In assessing an adult outpatient for airway clearance therapy, you notice the following: (1) no history of cystic fibrosis or bronchiectasis, (2) sputum production of 30 to 50 ml/day, (3) an effective cough, and (4) good hydration. Which of the following would you recommend?

a. postural drainage, percussion, and vibration
b. positive expiratory pressure therapy
c. mechanical insufflation-exsufflation
d. intrapulmonary percussive ventilation

Answer 98

ANS: B

See Figure